Rumsey, Karen TOq+N OF QUEEVBUP,
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director M 13 A C \
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Name r`/�If l'' F, Q--17M3C. L-11 Case#
Date Of Cremation P�
Time Cremation Started 1 6
Time Cremation Completed
Type of ContainerC�g \CL7-Ej2j- .LG� As c3 /►�L jo
Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
r� 6
(Name) }} (Sex)
(Street) (City) (State) ( Code)
who died on J day of IZ14 20 d
at V G ..3 S f Z
(Mace) (Aes)
Name and address of nearest living relative or name of person authorhIng cremation:
/1 , /V6 YL bar hU3 f
(Nam) (Address)
Relationship to the deceased b [ 1
Name of Funeral Home , C O A/"t J 2-,Pt
IMPORTANT:
I represent#0 to the best of my knowledge,the deceased(has)or no) maker,de--hrUlator or any other battery operated
device in his or her body. (Circle One)
1 certify that 1 have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all claims and demands for loss or damages which may be made agalost them
by reason of or cpnnpcted with the cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless,fa or
Ik (Address))ft s a L
nature and Address of Relative or Legal Representative)l Z(5R
Signed on this date: /S ��a
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006
TOWN OF QUEENSBURY C70
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
(Name) IJ F0vvt�T1� T (Sex)
S
(Street) (City) /(State) (Zip Code)
who died on � day ofjJrL4
s �
at CG�r�s �� ` ' ��Td' /f l Z
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
(Name) (Address)
Relationship to the deceased e 1r4 D4/
Name of Funeral Home Nutm
�" a
IMPORTANT:
I esent that to the best of my knowledge, the deceased has or
%as no pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization to arrange
for the cremation of the remains and to direct the disposition of
the cremated remains, that any personal possessions have either
been removed or may be destroyed, and- agree to protect, defend and
save harmless Pine View Crematorium from any and all claims and
demands for loss or damages which may be made against them by
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
ka
(Witness (Address )
(Signature of Relativt or Legal Rep. and Address )
Signed on this date: